Dr. Nicholas Muraguri is head of Kenya’s National AIDS/STI Control Programme. He spoke with John Donnelly about the scope of the country’s male circumcision outreach plan (170,000 Kenyan males were circumcised last year), the lessons learned, and a problem he sees ahead: funding not keeping up with increased demand for treatment, spurred in part by the circumcision outreach program. This is the final post in a series of interviews on male circumcision (MC), which has been proven to protect a man by up to 60 percent from contracting HIV during vaginal sex. For more information, check out the Center’s recent report “Medical Male Circumcision as HIV Prevention – Follow the Evidence: The case for aggressive scale up.”
What lessons have you learned in your campaigns to circumcise men in Kenya?
Two things are clear. First of all, you must have quality services. If I walk into the site, only my foreskin is removed and nothing else. No injuries or complications. The second point, we need to do this where people are. So outreach programs really are key, given the numbers we want to reach (200,000 men per year). You don’t wait for people to show up in the clinics. You take the services where they work, where they play, where they learn.
You do circumcisions in schools?
We are looking at above 15 years old.
During the school day?
We do this on holidays. Our main target is men who are sexually active – 18 to 35 years. But sexual debut in Kenya starts early. By 16 or 17 years old, most are sexually active.
What are your biggest challenges?
The challenges have been, first of all, creating sustained demand among the right groups. Also, you have to have very good systems for supplies, a good logistical system. You have to have good waste management; you need to cart waste away from there for disposal.
In many countries in eastern and southern Africa, demand is quite high. Has there been a drop-off in demand in Kenya?
No, demand is OK in general, but with the 18 to 35 year olds, we are dealing with competing priorities. A lot of them are working so that’s the challenge.
What’s the most important message you would have for others in Africa who might be starting up male circumcision programs?
The most important message is the issue of advocacy. People must understand why you are doing it, particularly in areas where circumcision is done for cultural reasons, not medical reasons. Message number two is having a good service delivery package. It’s not just cutting the foreskin. We talk about HIV prevention, risk-reduction counseling. We screen for STIs, we offer physical exams. We have identified more than 200 men who have congenital malformations of the penis, for instance. They didn’t know something could be done. So the message is, if you are just removing the foreskin, you are missing opportunities. Of those who come in for circumcision, 80 percent agree to do HIV testing. Most of them have never been tested for HIV before.
How long will it take for a man to go through this assembly line of services, including the operation?
Thirty to 45 minutes.
That’s it. First we do counseling, then surgery, then more counseling. We have five people seeing each patient: a doctor, two nurses, a counselor and an infection prevention specialist.
The U.S. government and other donor governments are facing tight budget constraints. Has this started to affect Kenya’s AIDS program?
We do not have waiting lists for treatment – not yet. But as revised guidelines for when treatment begins (with a higher CD4 count; now Kenya starts treatment at a 350 CD4 count), and as we scale up our circumcisions campaigns, we are going to get more and more people admitted to the treatment pool. More will be tested, and there will be pressure to scale up treatment.
What are you doing to prepare for a possible funding shortfall?
We have to develop a stability strategy. We are proposing to create a trust fund. We are seeing that the President’s Emergency Plan for AIDS Relief (PEPFAR) has level funding and the Global Fund to Fight AIDS, Tuberculosis and Malaria is not expanding. So we are looking at issues ahead, mobilizing community resources. Some of the ideas we are proposing are to have a small tariff on air time, with the mobile telephones, a small tax to support treatment. We are also proposing a small fee on airline tickets. The budget is a moving target. We need to be able to guarantee we will be able to finance the AIDS treatment program, and more and more people are coming in for treatment.
But we are one very lucky country. Those of us in Kenya, we have been very lucky people. PEPFAR just changed our lives, it has changed the lives of many, many Kenyans who have survived and now are taking care of their children and their families.